Prior Authorization Specialist

Description

About CLS Health

CLS Health is a growing healthcare system in Houston, Texas that is taking a different approach to healthcare. We are a physician-led healthcare group that focuses on providing patients with holistic, multispecialty care. We're a dynamic team on a mission to provide better healthcare options for Houstonians!

Position Summary

CLS Health is building an in-house molecular genetics laboratory and is hiring an experienced genetic testing authorization professional to run the front end of the program. This role requires prior experience securing coverage for genetic or molecular testing.

Candidates are expected to already understand how Medicare (MolDX), Texas Medicaid, and commercial lab benefit management programs evaluate genetic test requests and to apply that knowledge from day one across hereditary cancer, carrier screening, prenatal, pharmacogenomic, and somatic tumor testing.

This is a revenue-cycle role, not a clinical role . The Lead will:

• •Verify benefits.
• •Review orders against payer criteria.
• •Submit and track prior authorizations.
• •Communicate patient financial responsibility.
• •Work with physician offices to ensure orders are complete the first time.

As the program grows, the Lead will also help build the intake workflow in the EMR, train office staff, and supervise intake coordinators and in-office navigators.

Key Responsibilities Order Intake and Coverage Review

• •Review genetic test orders from CLS offices for completeness, including diagnosis, indication, family history, consent, and specimen requirements.
• •Verify benefits for every order and review each request against the payer’s medical policy and test-specific criteria.
• •Return incomplete orders to the ordering office the same day, with clear documentation of what is missing.

Prior Authorization and Patient Responsibility

• •Submit and track prior authorizations through payer portals and utilization management vendors such as Carelon and eviCore.
• •Coordinate peer-to-peer reviews and appeals with the ordering physician as needed.
• •Obtain test registration codes (such as DEX Z-Codes) where required by payers.
• •Prepare patient cost estimates and Advance Beneficiary Notices (ABNs) for non-covered tests before specimen collection.
• •Maintain a reference of coverage criteria by test and payer, including Medicare, Texas Medicaid and its MCOs, BCBSTX, UnitedHealthcare, Aetna, Cigna, and Humana.

Workflow, Training, and Team Leadership

• •Build and maintain the intake workflow in the EMR in partnership with IT and the Laboratory Manager.
• •Train office staff on ordering and documentation requirements.
• •Supervise intake coordinators and in-office genetics navigators as the team grows.
• •Report weekly on order volume, pending authorizations, approvals, denials, turnaround times, and cancellations.

Performance Expectations

• •Verify benefits within 1 business day of receiving an order.
• •Submit prior authorizations within 2 business days of receiving a complete order.
• •Keep a documented next action and due date on every open request.
• •Ensure no test is performed without required authorization.

Requirements

• •2+ years of prior authorization or benefits verification experience specifically for genetic or molecular testing, at a genetics laboratory, molecular diagnostics company, academic genetics program, or payer utilization management vendor.
• •Working knowledge of genetic testing coverage policies across Medicare/MolDX, Texas Medicaid and its MCOs, and commercial payers, and of lab benefit management programs such as Carelon, eviCore, and Avalon.
• •Experience with molecular pathology CPT coding (81xxx and PLA codes), DEX Z-Code registration, and medical necessity documentation for genetic tests.
• •Experience handling peer-to-peer reviews, appeals, and ABN and cost estimate conversations for genetic testing.
• •Ability to work directly and effectively with physicians and office staff.
• •High school diploma or GED.

Preferred

• •Experience at a national genetic testing laboratory (for example Natera, Myriad, Invitae, GeneDx, or Ambry) or a genetics-focused billing company.
• •Experience building intake or authorization workflows in an EMR; eClinicalWorks a plus.
• •Lead or supervisory experience.
• •Associate or bachelor's degree, or a coding or revenue-cycle certification.